Effective Date: March 2, 2016

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1 Medical Review Criteria Varicose Vein Procedures Effective Date: March 2, 2016 Treatmetn Subject: Varicose Vein Procedures VeinTreatment of Varicose Policy: Veins HPHC covers specific non-experimental procedures that are reasonable and medically necessary for the treatment of symptomatic refluxing varicose veins 1 of the lower extremity. Covered procedures include: Ambulatory Phlebectomy (Stab or Hook Phlebectomy) Endovenous Laser Ablation (EVLA) Endovenous Radiofrequency Ablation (RFA) Ligation and Stripping Sclerotherapy associated with other vein procedures Subfascial Endoscopic Perforator Surgery (SEPS) Transilluminated Powered Phlebectomy (TIPP) Authorization: Prior authorization is required for varicose vein procedures provided in any setting (e.g. physician office, outpatient/ambulatory setting, surgical day care center) to members enrolled in Core (HMO, POS, PPO) products. General Eligibility Criteria for Axial Reflux: 1. Documentation confirms a history of ANY of the following: Varicose vein(s) with significant symptoms (e.g., persistent pain, swelling, dependent heaviness, throbbing) that interfere with activities of daily living*; Open or healed venous ulcer 2 ; Significant lipodermatosclerosis (LDS) related to venous insufficiency; Ruptured superficial varicosity with hemorrhage 3 ; Persistent or recurrent (>2 episodes) symptomatic superficial thrombophlebitis*. Persistent, symptomatic superficial thrombophlebitis.* *For members with symptomatic varicose veins or symptomatic superficial thrombophlebitis, there must be documentation demonstrating symptoms did not respond after at least 6 weeks of conservative therapy including use of appropriate 1 Varicose veins are abnormally enlarged and tortuous vessels that result when veins become incompetent, venous valve leaflets no longer meet in the midline, and this failure allows blood to flow in a retrograde direction (reflux). Varicose veins are most often noted on the back of the calf or on the inside of the leg between the groin and ankle, but can occur anywhere on the extremity. 2 Treatment may be authorized for the prevention of ulcer recurrence. 3 Treatment is usually authorized after 2 or more episodes of minor hemorrhage, but may be authorized after a single episode of hemorrhage if a varix remains in an area prone to trauma (e.g. pretibial area), or if transfusion was required. Varicose Vein Procedures Page 1 of 6

2 prescription generated, pressure gradient compression stockings (> mm Hg), and NSAIDs (unless NSAIDs are contraindicated or not tolerated). 2. Duplex ultrasound of the deep and superficial venous system (performed while patient is standing) confirms ANY of the following: Reflux >1 second and venous diameter 3 mm in Great Saphenous Vein (GSV), Small Saphenous Vein (SSV), or Anterior Accessory Great Saphenous Vein (AAGSV). 4 Documentation should note venous measurements along the refluxing axial veins in scope of treatment. Nonaxial varicose veins with diameter 3mm (by physical exam or ultrasound). Ultrasound documented competency or confirmation of successful ablation/removal of axial veins is required. Pathologic perforating veins (i.e., outward flow of >500 msec duration, with a diameter of >3.5mm) located beneath or associated with the ulcer bed, and no post thrombotic deep system incompetence If GSV, SSV, or AAGSV is connected to this area, there must be documentation confirming the superficial vein has been successfully ablated/removed, and despite this treatment, the ulcer has not healed or has recurred. Vein/Procedure List: For members with conditions listed below, the following procedures or combination of procedures may be authorized when General Eligibility Criteria (above) are met: Procedure Ambulatory Phlebectomy Direct Open Ligation (under ultrasound) Endovenous Laser Ablation (EVLA) Endovenous Radiofrequency Veins Involved mm; OR Symptomatic secondary varicosities in the same vein field, in conjunction with, or after a successful main axial superficial vein ablation/removal performed within the past year. Authorized for pathologic perforator vein(s) directly associated with a venous ulcer. GSV, SSV, or AAGSV with reflux >1 second and venous diameter 3 mm; OR mm; OR Pathologic perforator vein directly associated with a venous ulcer 4 Refluxing and enlarged axial veins must connect to symptomatic varicose veins, leg ulcer, or area of lipodermatosclerosis. Varicose Vein Procedures Page 2 of 6

3 Procedure Ablation (RFA) Ligation and Stripping Sclerotherapy (limited to a maximum of 3 procedures per vein field). Subfascial Interruption or Subfascial Endoscopic Perforator Vein Surgery (SEPS) Transilluminated Powered Phlebectomy (TIPP) Veins Involved GSV, SSV, or AAGSV with reflux >1 second and venous diameter 3 mm; OR mm Pathologic perforator vein directly associated with a venous ulcer Authorized for GSV, SSV, or AAGSV with reflux >1 second and venous diameter 3 mm. Symptomatic secondary varicosities in the same vein field, in conjunction with, or after a successful main axial superficial vein ablation/removal performed within the past year; sclerotherapy authorized for remaining veins 3mm and 6 mm diameter Pathologic perforator vein directly associated with a venous ulcer 5 Authorized for pathologic perforator vein(s) directly associated with a venous ulcer. mm; OR Symptomatic secondary varicosities in the same vein field, in conjunction with, or after a successful main axial superficial vein ablation/removal performed within the past year. (TIPP authorized for remaining veins 3mm in size) Exclusions: Treatment of varicose veins without significant symptoms, or in situations where HPHC Coverage Criteria are not met Cosmetic services 6 or surgery including treatment of spider veins, broken blood vessels, reticular veins, or telangiectasias Investigational protocols or devices not listed above, including (but not limited to): External transdermal photocoagulation or laser coagulation. Intensive Pulsed Light therapy. Endomechanical ablation using a percutaneous infusion catheter (e.g., ClariVein system) 5 Sclerotherapy usually performed with Duplex guidance. 6 Cosmetic services (i.e., surgery, procedures or treatments performed primarily to reshape or improve the patient's appearance) are not usually considered medically necessary, even when intended to improve an individual s emotional well-being or treat a mental health condition. Varicose Vein Procedures Page 3 of 6

4 Varithena (poolidocanol injectable foam) 1% VenaSeal Closure System Liquid or foam sclerotherapy (including Varithena [polidocanol injectable foam 1%])or echosclerotherapy, performed for any of the following: Treatment of main axial veins (GSV, SSV, AAGSV) Sole treatment for varicose non-axial veins and varicose tributaries without associated or prior successful ablation of the main axial veins Treatment of incompetent perforator veins without ulceration Treatment of veins < 3 mm and > 6 mm diameter Conditions where treatment is contraindicated (e.g., by pregnancy, fever, prolonged limb immobilization, arterial insufficiency, coagulopathy or anticoagulation treatment, acute active thrombophlebitis) Coding: Codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive. Deleted codes and codes which are not effective at the time the service is rendered may not be eligible. CPT Code Description Injection of sclerosing solution; single vein Injection of sclerosing solution; multiple veins, same leg Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS) Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions Ligation, division, and stripping, short saphenous vein Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below Varicose Vein Procedures Page 4 of 6

5 37735 Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open,1 leg Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg Stab phlebectomy of varicose veins, 1 extremity; stab incisions Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) Ligation, division, and/or excision of varicose vein cluster(s), 1 leg Review/Revision History: Approved by UMCPC: 3/1/16 Revised: 11/05, 12/06, 10/07, 10/08, 12/09, 12/10, 12/11, 11/12, 1/14, 2/15. 2/16 Initiated: 11/04 (Replaced InterQual ISP VS 51-52) Summary of Changes: Date Revisions 2/24/16 Added coding profile. Added exclusion: VenaSeal 2/15/15 Revise format. Update terminology (e.g., pathologic perforator vein) and references. References: 1. Siribumrungwong et al. A systematic review and meta-analysis of randomized controlled trials comparing endovenous ablation and surgical intervention in patients with varicose vein. Eur J Vasc and Endovasc Surg. 2012; 44: Gloviczki et al. The care of patients with varicose veins and associated chronic venous disease: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011; 53:2S-48S. 3. Murad et al. A systematic review and meta-analysis of the treatments of varicose veins. J Vasc Surg. 2011; 53: 49S-65S. 4. Nesbit et al. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus conventional surgery for great saphenous vein varices (review). Cochrane Collaboration. Cochrane Library. 2011; Issue Rasmussen, LH et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011; 98: O Donnell, TF. The role of perforators in chronic venous insufficiency. Phlebology. 2010; 25: Leopardi et al. Systematic Review of Treatments for Varicose Veins. Ann Vasc Surg. 2009; 23: Van den Bos et al. Endovenous therapies of lower extremity varicosities: A meta-analysis. J Vasc Surg Jan; 49(1): Epub 2008 Aug 9. Varicose Vein Procedures Page 5 of 6

6 9. Van den Bos et al. Technical Review of Endovenous Laser Therapy for varicose veins. Eur J Vasc Endovasc Surg Jan; 35(1): Epub 2007 Oct Pannier et al. Endovenous laser therapy and radiofrequency ablation of saphenous varicose veins. J Cardiovasc Surg (Torino) Feb; 47(1): Darwood et al. Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg Mar; 95(3): Luebke et al. Meta-analysis of subfascial endoscopic perforator vein surgery (SEPS) for chronic venous insufficiency. Phlebology Feb; 24(1): Carradice et al. Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins Br J Surg 2008; 95(Suppl 6): 6 and Int Angiol 2008; 27(Suppl 1): Mekako et al. Combined Endovenous Laser Therapy and Ambulatory Phlebectomy: Refinement of a New Technique. Eur J Vasc Endovasc Surg 32, 725e729 (2006) 15. Smith P C Foam and liquid sclerotherapy for varicose veins. Phlebology 2009; 24 Suppl 1: NICE Clinical Guideline 168: Varicose Veins in the Legs; The diagnosis and management of varicose veins: Issued July O D O Donnell TF, Passman M (editors) Clinical practice guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF): Management of venous leg ulcers. J Vasc Surg. 2014; 60: 1S-90S. PMID: Varicose Vein Procedures Page 6 of 6